Phil’s Social Security Weblinks

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This list literally was years in the making. Please let me know if a link is broken. Thanks.

Current Social Security Benefits and Taxes
https://www.ssa.gov/cola/

Contribution and Benefit Base
https://www.ssa.gov/oact/cola/cbb.html

How You Earn Credits
https://www.socialsecurity.gov/pubs/EN-05-10072.pdf

Primary Insurance Amount
http://www.ssa.gov/oact/cola/piaformula.html

Average Indexed Monthly Earnings
http://www.ssa.gov/oact/cola/Benefits.html

Substantial Gainful Activity
https://www.socialsecurity.gov/oact/cola/sga.html

my Social Security
http://www.ssa.gov/myaccount/

SS Office Locator
https://secure.ssa.gov/ICON/main.jsp

Apply for Social Security Retirement Benefits
https://www.ssa.gov/forms/apply-for-benefits.html

Apply for Social Security Disability Benefits
https://www.ssa.gov/disability/disability.html

Taxation of benefits
http://www.ssa.gov/planners/taxes.htm

Retroactive Benefits
https://www.ssa.gov/OP_Home/handbook/handbook.15/handbook-1513.html

Full Retirement Age
https://www.ssa.gov/planners/retire/ageincrease.html

Delayed Retirement Credits
https://www.ssa.gov/planners/retire/delayret.html

Retirement Planner: 2015 Social Security Claiming Changes
https://www.ssa.gov/planners/retire/claiming.html

Deeming for Retirement and Spouse’s Benefits
https://faq.ssa.gov/en-us/Topic/article/KA-01202

Earnings Test
http://www.ssa.gov/oact/cola/rtea.html

How Work Affects Your Benefits
http://www.socialsecurity.gov/pubs/EN-05-10069.pdf

Benefits For Your Family
Includes Maximum Family Benefits, Benefits for Your Spouse, Benefits for Your Children, Benefits for Your Divorced Spouse, and How Do You Apply
https://www.ssa.gov/benefits/retirement/planner/applying7.html

Benefit Calculators
https://www.ssa.gov/oact/anypia/index.html

Early or Late Retirement?
https://www.ssa.gov/oact/quickcalc/early_late.html

Benefit Reduction for Early Retirement
https://www.ssa.gov/oact/quickcalc/earlyretire.html

Benefits for Spouses
https://www.ssa.gov/oact/quickcalc/spouse.html

Ex-spousal benefits
http://www.ssa.gov/retire2/yourdivspouse.htm

Survivor Benefits
https://www.ssa.gov/benefits/survivors/

If You Are the Survivor
https://www.ssa.gov/benefits/survivors/ifyou.html

Early survivor benefits
https://www.ssa.gov/planners/survivors/survivorchartred.html

Remarriage rules for survivor benefits
https://www.ssa.gov/OP_Home/handbook/handbook.04/handbook-0406.html

Tax treatment of different types of income
https://secure.ssa.gov/poms.nsf/lnx/0302505240

Benefits for Children
http://www.ssa.gov/pubs/EN-05-10085.pdf

Family Maximum Benefit
http://www.ssa.gov/oact/cola/familymax.html

Formula for family maximum benefit
https://www.ssa.gov/oact/cola/familymax.html

Combined Family Maximum Benefit
https://secure.ssa.gov/apps10/poms.NSF/lnx/0300615770

Understanding the Social Security Family Maximum
https://www.ssa.gov/policy/docs/ssb/v75n3/v75n3p1.html

PIA and Family Maximum Computations
https://secure.ssa.gov/apps10/poms.nsf/lnx/0300605900

Average Indexed Monthly Earnings (AIME) PIA Chart
https://secure.ssa.gov/apps10/poms.nsf/lnx/0300605905

Family Maximum Chart
https://secure.ssa.gov/apps10/poms.nsf/lnx/0300605910

Social Security and Equivalent Railroad Retirement Benefits
https://www.irs.gov/pub/irs-pdf/p915.pdf

Suspending Retirement Benefits
http://www.ssa.gov/retire2/suspend.htm

If You Change Your Mind
https://www.ssa.gov/planners/retire/withdrawal.html

Request for Withdrawal of Application
https://www.ssa.gov/forms/ssa-521.pdf

Government Pension Offset
http://www.ssa.gov/pubs/EN-05-10007.pdf

Windfall Elimination Provision
http://www.ssa.gov/pubs/EN-05-10045.pdf

National Academy of Elder Law Attorneys (NAELA)
https://www.naela.org/

What Prisoners Need to Know
https://www.ssa.gov/pubs/EN-05-10133.pdf

Social Security Disability Fee Agreements
https://www.ssa.gov/representation/fee_agreements.htm?

Non-Medical Appeal
https://secure.ssa.gov/iApplNMD/start

Form SSA-561 — Request for Reconsideration
https://www.ssa.gov/forms/ssa-561.html

Accidental Death
May permit earlier claiming eligibility
https://secure.ssa.gov/apps10/poms.nsf/lnx/0200305105

Policy for the scope of an application
Section D covers restricted applications
A claimant may choose to limit or restrict the scope of the application to exclude a class of benefits he or she may be eligible to on one or more SSNs for any reason (except where deemed filing applies). The reason may be to receive higher current benefits or to maximize the amount of benefits over a period of time, including the effect of delayed retirement credits (DRCs). (See RS 00615.480 for information on adjustment of the reduction factor.)
https://secure.ssa.gov/apps10/poms.nsf/lnx/0200204020Representing Social Security Claimants
https://www.ssa.gov/representation/

Form for appointing a legal representative
https://www.ssa.gov/forms/ssa-1696.pd

Medicare Part D 2024 drug plan rules

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The Inflation Reduction Act continues to be the big news for Part D drug plans. Here are major provisions of the new law, which was passed in 2022:

In 2023, the cost to consumers of insulin in Part D drug plans was capped at $35 a month for covered insulin, with no deductibles. Drug companies also began paying penalties — to Medicare, not you, unfortunately — if they increased prices by more than the general rate of inflation.

In 2024, people with high drug costs will no longer have to pay 5 percent for their drugs when they are in what’s called the catastrophic phase of their Part D plan. This phase is triggered when your spending and certain spending by your plan have reached $8,000

Medicare low-income drug support payments will be expanded.

From the years 2024 to 2030, annual Part D premium increases can be no more than six percent.

In 2025, out-of-pocket drug costs will be capped at $2,000 a year.

And in 2026, for the first time, Medicare will have the right to negotiate drug prices with pharmaceutical companies.

The maximum annual deductible will increase to $545 from $503 in 2023. Some plans set lower deductibles.

KFF has a detailed assessment of 2024 Part D plans.

 

2024 Social Security Benefits Rise 3.2%

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The Social Security cost-of-living adjustment (COLA) for 2024 is 3.2 percent, far less than this year’s 8.7 percent COLA. The ceiling on earnings subject to payroll taxes is $168,600, up from $160,200 in 2023.

The agency bases the COLA on consumer price inflation for the year ending September 30. The rate of inflation was sharply lower in 2023 than 2022.

The COLA also affects other Social Security benefit formulas. Here is the agency’s fact sheet. Apologies for the clunky appearance. Some of the terms may be obscure. If a visit to your favorite search engine does not explain something clearly, let me know and I’ll respond.

2024 Part B Premium up 6% to $174.70

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Medicare’s Part B monthly premium is $174.70 in 2024 – an increase of $9.80, or 6 percent, from $164.90 in 2023. The annual Part B deductible, which most people must pay before their Medicare coverage begins, is $240, up by $14, or 6.2 percent, from $226 last year. Part B covers doctors, medical equipment, and outpatient expenses.

The deductible for Part A is $1,632 in 2024, up from $1,600 this year. Two-percent increases will also be applied to coinsurance programs for hospital and skilled nursing care. Part A of Medicare covers inpatient care in hospitals and skilled nursing facilities, hospice, inpatient rehabilitation, and some in-home care.

Part A is funded by Social Security payroll taxes. People who pay payroll taxes for at least 40 quarters during their working lives do not pay premiums for Part A. For the small percentage of those who do not qualify, Part A premiums dipped by $1 to $505 a month for those with fewer than 30 quarters of covered earnings; they are unchanged at $278 a month for people with between 30 and 40 quarters of covered earnings. The Part A deductible is for an episode of care, not for the entire year. An episode is usually defined as the time spent on claim plus an additional 60 days. It’s thus possible to have more than a single deductible in a calendar year.

High-income Medicare surcharges apply additional premiums for Part B and Part D drug plans for about 8 percent of the highest-earning Medicare enrollees. Those rates were raised about 6 percent from 2023 levels:

Phil’s Medicare Weblinks

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This list literally was years in the making. Please let me know if a link is broken. Thanks.

My Medicare
https://www.mymedicare.gov/

Help with your Medicare choices
https://www.medicare.gov/medicarecoverageoptions/

When can I join, switch, or drop a plan?
http://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html

Special Enrollment Periods
[THIS LINK APPLIES TO MA AND PART D]
https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances-special-enrollment-periods

Get started with Medicare
https://www.medicare.gov/basics/get-started-with-medicare

Original Medicare enrollment periods
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-sign-up-parts-a-and-b/when-sign-up-parts-a-and-b.html

Medicare’s annual enrollment period is October 15 – December 7
http://www.cms.gov/Center/Special-Topic/Open-Enrollment-Center.html

Medicare Advantage open enrollment period
https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html#collapse-3192

Working past 65
https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/working-past-65

Request for Employment Information
(automatic download of PDF)
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.pdf

Application for Enrollment in Medicare Part B
(automatic download of PDF)
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf

Medicare savings programs for lower-income beneficiaries
http://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html

The Federal Employees Health Benefits Program and Medicare
(automatic download of PDF)
https://www.opm.gov/healthcare-insurance/healthcare/medicare/75-12-final.pdf

Medicare & You
(automatic download of PDF)
https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

Contact Medicare
https://www.medicare.gov/Contacts/

Medicare costs
https://www.medicare.gov/basics/costs/medicare-costs

Does your provider accept Medicare as full payment?
https://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-and-assignment.html

Concierge care
https://www.medicare.gov/coverage/concierge-care.html

IRS Publication 969
Health Savings Accounts and Other Tax-Favored Health Plans
(automatic download of PDF)
https://www.irs.gov/pub/irs-pdf/p969.pdf

How a non-working spouse can get premium-free Part A
https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801008

What Part A covers
https://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html

What Part B covers
https://www.medicare.gov/what-medicare-covers/what-part-b-covers.html

Form to Terminate Part A and/or B
(automatic download of PDF)
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1763.pdf

Inpatient hospital care
https://www.medicare.gov/coverage/hospital-care-inpatient.html

Medicare Coverage of Skilled Nursing Facility Care
(automatic download of PDF)
www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf

Medicare Hospice Benefits
(automatic download of PDF)
https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF

How Hospice Works
https://www.medicare.gov/what-medicare-covers/what-part-a-covers/how-hospice-works

Hospice
https://www.medicare.gov/coverage/hospice-and-respite-care.html

Medicare Dental Coverage
https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html

Is my test, item, or service covered?
https://www.medicare.gov/coverage/your-medicare-coverage.html

Home health services
https://www.medicare.gov/coverage/home-health-services.html

Find a home health agency
https://www.medicare.gov/homehealthcompare/search.html

Durable medical equipment (DME) coverage
https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html

Your Guide to Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program
(automatic download of PDF)
https://www.medicare.gov/sites/default/files/2022-02/11461-DMEPOS-Competitive-Bidding-Program-Guide.pdf

Medicare Coverage of Kidney Dialysis & Kidney Transplant Services
https://www.medicare.gov/Pubs/pdf/10128-Medicare-Coverage-ESRD.pdf

Who are the MACs
https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#ABandHH+H

Medicare Part B Income-Related Monthly Adjustment Amounts
https://www.cms.gov/newsroom/fact-sheets/2024-medicare-parts-b-premiums-and-deductibles

What Is the Difference Between AGI and MAGI on Your Taxes?
https://turbotax.intuit.com/tax-tips/irs-tax-return/what-is-the-difference-between-agi-and-magi-on-your-taxes/L7kHckNS3

IRMAA Life-Changing Event form
(may not be updated with 2023 IRMAA brackets)
https://www.ssa.gov/forms/ssa-44-ext.pdf

Medicare Premiums: Rules for Higher-Income Beneficiaries
https://www.ssa.gov/benefits/medicare/medicare-premiums.html

Medicare Part B IRMAA Premium Appeals
https://www.hhs.gov/about/agencies/omha/the-appeals-process/part-b-premium-appeals/index.html

Avoid late enrollment penalties
https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty

Acknowledgment of Request for Medicare Premium Part A Termination
(automatic download of PDF)
https://secure.ssa.gov/apps10/poms/images/Other/G-CMS-L458-1.pdf

How do I terminate my Medicare Part B (medical insurance)?
https://faq.ssa.gov/en-us/Topic/article/KA-02713

Request for Termination of Premium Hospital and/or Supplementary Medical Insurance
(automatic download of PDF)
www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1763.pdf

Request for Reconsideration
[Used to appeal Social Security Medicare enrollment decisions]
(automatic download of PDF)
https://www.ssa.gov/forms/ssa-561.pdf

Workers’ Compensation Medicare Set Aside Arrangements
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Overview.html

What’s Medicare Supplement Insurance (Medigap)?
http://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

2022 Choosing a Medigap Policy
(automatic download of PDF)
www.medicare.gov/sites/default/files/2022-03/02110-medigap-guide-health-insurance.pdf

Find a Medigap policy that works for you
https://www.medicare.gov/find-a-plan/questions/medigap-home.aspx

When can I buy Medigap?
http://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html

Medigap guaranteed issue rights
https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights

Kaiser Family Foundation
Medigap Enrollment and Consumer Protections Vary Across States
(automatic download of PDF)
http://files.kff.org/attachment/Issue-Brief-Medigap-Enrollment-and-Consumer-Protections-Vary-Across-States

PART C – MEDICARE ADVANTAGE

Medicare Advantage Plans
https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/medicare-advantage-plans

Find Medicare health & drug plans
https://www.medicare.gov/find-a-plan/questions/home.aspx

Medicare Special Needs Plans (SNP)
https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/special-needs-plans-snp

PART D – PRESCRIPTION DRUGS

Your Guide to Prescription Drug Coverage
(automatic download of PDF)
https:es.medicare.gov/publications/11109-Medicare-Drug-Coverage-Guide.pdf

Monthly premium for drug plans
https://www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html

How Part D works with other insurance
http://www.medicare.gov/part-d/how-part-d-works-with-other-insurance/part-d-and-other-insurance.html#collapse-2324

Extra Help for Part D drug costs
http://www.ssa.gov/medicare/prescriptionhelp/

Costs in the coverage gap (the “donut hole”)
https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap

Part D late enrollment penalty
http://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html
Find a Pharmaceutical Assistance Program for the drugs you take
https://www.medicare.gov/pharmaceutical-assistance-program/

HELP

Filing complaints about your health or drug plan
https://www.medicare.gov/claims-appeals/file-a-complaint-grievance/filing-complaints-about-your-health-or-drug-plan

State Health Insurance Assistance Program (SHIP)
https://www.shiphelp.org/

Medicare Rights Center

Getting Medicare right.

The Center for Medicare Advocacy
http://www.medicareadvocacy.org/

National Academy of Elder Law Attorneys
https://www.naela.org/

National Association of Area Agencies on Aging
http://www.n4a.org/

OTHER RETIREE HEALTH PLANS

TRICARE For Life
http://www.tricare.mil/tfl

Veterans Health Administration
http://www.va.gov/health/programs/index.asp

 

 

 

Accountable Care Organizations May Dominate Original Medicare

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Original Medicare consists of Parts A and B, a Part D drug plan, and usually a Medigap supplement plan that plugs holes in what Parts A and B pay for approved claims. This is known as fee-based care. It works well but the care recommended by your doctors and hospitals generally is approved with no effort to determine its impact on your health. This leads to more care that may do little for your health while costing Medicare a lot of money.

Value-based care, by contrast, is linked to your health. Doctors and other providers can be financially rewarded for good health outcomes, even if they involve providing less health care.

The push to encourage value-based care is being led by groups of doctors and affiliated health providers who have been creating what are called “accountable care organizations,” or ACOs. The Centers for Medicare & Medicaid Services has supported several programs in recent years to evaluate different approaches. The big challenge is devising a payment system that rewards doctors enough for positive patient outcomes to compensate them for the reduced volumes of care they have enjoyed under fee-for-service Medicare.

The agency is still searching for the sweet spot here. Nonetheless, it announced last year that its goal was that everyone with Original Medicare would be in an ACO by the year 2030. That’s upwards of 30 million people.

At their best, ACOs weed out unproductive care and focus on treatments that make patients healthier. Potentially, these treatments could involve much more preventive care and even financial support for non-medical care such as better nutrition and healthier living conditions. Primary doctors are the stars of ACOs, providing patient-centric care tailored to individual needs.

The program’s greatest potential is in serving what are called “high-risk” patients. These folks have multiple health issues and run up big medical bills. Improving their health can provide large returns for value-based care.

Consumers generally know little about ACOs, including whether they’re even in one. But there’s a good chance you are, and these odds are rising. “Overall, in 2024 there are about 13.7 million people with Traditional Medicare aligned to an ACO,” the agency reports. “ACOs are now serving nearly half of the people with Traditional Medicare, a 3 percent increase since 2023.”

The agency will have to do better than 3 percent annual growth to meet its 2030 goal. I urge you to find out if you’re in an ACO and to ask your doctor about how your care could change as a result. They may not have great answers yet. ACOs are new to them, too, but changes are coming.

Dental Benefits Expanding in Original Medicare

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Original Medicare does not cover routine dental care, whereas some Medicare Advantage plans do. This is a big draw for MA plans. Original Medicare is not allowed to offer such coverage, contributing to a widespread view that the government is stacking the deck in favor of private insurance plans.

Original Medicare does, however, cover dental surgery related to other health problems that are covered by Medicare. The extent and consistency of such coverage regularly disappoint dental groups, and they view the enhancements to this coverage as a major win.

Here is the explanation from the Centers for Medicare & Medicaid Services (CMS) of key changes in Medicare dental coverage it announced in 2023:

“Medicare Part B currently pays for dental services when that service is integral to medically necessary services required to treat a beneficiary’s primary medical condition. Some examples include reconstruction of the jaw following accidental injury or tooth extractions done in preparation for radiation treatment for jaw cancer. CMS is proposing to pay for dental services, such as dental examination and treatment preceding an organ transplant.

In addition, CMS has sought comment on other medical conditions where Medicare should pay for dental services, such as for cancer treatment or joint replacement surgeries, as well as on a process to get public input when “additional dental services may be integral to the clinical success of other medical services.”

A consortium of more than 230 health and senior advocacy groups applauded the proposals. “This important announcement marks a new day in the health of Medicare beneficiaries,” said consortium member Dr. Michael Alfano, with the Santa Fe Group. “Thanks to the tireless work of literally hundreds of organizations and thousands of dedicated advocates, Americans will no longer lack access to medically necessary oral and dental treatment within the traditional Medicare program.”

All Medicare beneficiaries, including those with MA plans, will benefit from broader coverage of medically needed dental care. The changes won’t take effect anytime soon, but do represent a major advancement in oral health for tens of millions of older and disabled people.

 

Part B Medicare Premiums Will Decline in 2023

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Part B premiums will decrease to $164.90 a month in 2023 from $170.10 this year. The annual Part B deductible will also decline, to $226 from $233. Part B covers doctors, medical equipment and other outpatient expenses. The last year-to-year decline was in 2012, when the monthly Part B premium was reduced to $99.90 from $115.40.

The reductions stem from Medicare’s controversial decision in late 2021 to jack up 2022 premiums in anticipation the program would have to cover an expensive new Alzheimer’s drug called Aduhelm. However, that drug was never approved for widespread use.

The Centers for Medicare and Medicaid Services (CMS) resisted subsequent calls to lower premiums last year, saying mid-year changes were not feasible. But it promised to address the problem in its 2023 premium decisions.

Here’s more on the agency’s travails with Aduhelm:

On May 27, the Centers for Medicare & Medicaid Services (CMS) said it would not change Part B premiums this year, even though half of the financial justification for its whopping 14.5 percent increase in 2022 premiums has not materialized. It did say it expected 2023 premiums to decline, but in the meantime, Medicare beneficiaries must continue paying the higher premiums.

The agency based its decision on a long-awaited report that concluded that changing Part B premiums prior to next year would be impractical and that the agency has no rules or process for anything other than annual changes to Medicare premiums.

Last fall, when the 2022 increases were announced, CMS said half of the expected rise was an insurance policy of sorts against the possibility that Adulhelm, an expensive new dementia drug, would lead to huge increases in Part B spending. The drug must be administered by licensed caregivers and thus is covered under Part B and not Part D of Medicare, which covers prescription drugs. Part B covers doctors, medical equipment, and other outpatient expenses.

The 2022 monthly Part B premium rose by $21.60, or nearly 15 percent, to $170.10 from $148.50 in 2021. It was more than double the projected $10 boost included in the annual report from Medicare program trustees that was released last August.

At the time, CMS said, “Depending on utilization, the potential costs for this course of treatment range from negligible to very significant. To ensure that Part B is able to pay claims in full and on time, the Part B financing must be sufficient to provide for a realistic high-cost scenario of Aduhelm coverage. The contingency margin has been increased to accommodate this risk.”

It has spent much of the past six months defending itself against criticism of the increase.

The rational for basing a large part of its 2022 premium increases on possible Adulheim claims began crumbling even before the end of last year.

On Dec. 20, Adulhelm’s manufacturer, Biogen, said it would halve the drug’s annual price from $56,000 to $28,200. Many Medicare organizations urged CMS then to reduce Part B premiums. In response, on January 10, Xavier Becerra, head of the U.S. Department of Health & Human Services, asked CMS to reassess the amount of the Part B premium increase.

Later, in April, CMS issued what’s called a national coverage determination that said coverage of Aduhelm would be sharply limited to its use in clinical trials.

Becerra had earlier signaled that 2022 Medicare Part B premiums could be cut if Medicare later decided to limit coverage of the drug. “Once we have that determination, we’ll be able to fully assess what impact Aduhelm may have had on premiums for seniors in Medicare,” Becerra was quoted in a STAT story. “We’re gonna make sure that seniors don’t pay more than they have to.”

That position disappeared Friday. In its report and an accompanying press release, CMS used a lot of spin to cast its decision in the most favorable light. The fact that it announced the action on the Friday afternoon before the long Memorial Day weekend was a clear sign that it wanted to minimize attention to what is sure to be an unpopular decision.

At the very least, much of the rational for not changing premiums should have been known to agency officials without needing the political cover of a formal study of the matter.

Here are the self-serving highlights from the CMS press office. These are quotes from the release:

Given the information available today, it is expected that the 2023 premium will be lower than 2022. The final determination will be made later this fall.

The Biden-Harris Administration remains committed to lowering health care costs for beneficiaries by increasing price transparency, lowering the cost of prescription drugs, and connecting people to savings programs.”

Despite the increase, most people with Medicare saw a significant net increase in Social Security benefits due to a higher-than-usual Cost of Living Adjustment (COLA) in 2022.

Here is the report’s explanation of the agency’s decision. Again, these are quotes from the report:

The Part B premium has never been redetermined; rather, the statute requires that the determination of the premium be made for the entire succeeding year and does not explicitly include a basis for a redetermination.

Any additional funding caused by including the uncertainty of potential Aduhelm costs in the 2022 premium will be used to reduce the necessary financing in 2023 and later.

It is also worth noting that administering a redetermination of the 2022 Part B premium would be extremely burdensome. These complications, such as reprogramming the Social Security Administration systems, would take a significant amount of time and other resources, as described in greater detail elsewhere.

CMS found that incorporating the premium effects of Aduhelm’s price reduction and the subsequent National Coverage Determination into the 2023 premium is the only practically feasible option, as implementing a mid-year administrative redetermination of the 2022 premium was not found to be operationally possible during 2022, and also determined CMS does not have sufficient authority to send premium refunds directly to beneficiaries unless there is excess payment relative to the established premium.

The premium for each Medicare beneficiary is determined based on individual factors such as date of enrollment, requirements to pay penalties for late enrollment, income, disability status, the hold harmless provision, dual eligibility for Medicare and Medicaid, premium assistance, and other factors. For some beneficiaries, these factors change throughout year. CMS maintains files on beneficiary enrollment but relies on other entities to calculate, collect, and pay premiums, and update the base premium annually. The processes required for a mid-year change exceed the tested capabilities of some of these involved entities and were estimated to stretch late into 2022 if not early 2023, thus practically invalidating the benefit of setting a new premium mid-year. This timeline also risked disrupting the smooth implementation of the 2023 Part B premium.

A mid-year redetermination would also require a corresponding update to the Part B deductible, as the Part B deductible amount is linked to the amount of the Part B Premium. Such a change would require the retroactive reprocessing of millions of claims, which would take over a year and additional resources to complete as well as the attempted reimbursement of beneficiaries for past cost sharing through their health care providers.

 

 

Health care is moving into your home

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It usually requires only three reinforcing trends to fire up my punditry genes, but there are even more when it comes to the likelihood that older Americans will be able to age in place successfully, in large measure because their health care will be delivered to them at home.

In no particular order, they include the Pandemic, health care technology, a shortage of health care workers, the ugly profile of life in a nursing home, soaring hospital costs, the dearth of long-term care, and Baby Boomers, who are growing both in numbers and chronic health problems.

Oh, and don’t forget trillions of dollars in new infrastructure and health spending contained in the two massive bills now making their way through Congress.

Let’s explore them in order.

COVID-19, which seems likely to morph into COVID-21 and so on, is involved in many factors affecting home-based care.

It forced everyone to spend time at home. Once there, we liked what we saw, and have been pouring enormous sums into fixing up and expanding our homes. Home-centric life isn’t going to change anytime soon.

The Pandemic also created enormous pressures on the existing health-care infrastructure. We don’t have enough hospital beds, nurses, doctors, and other health workers. This also triggered the movement of health care to the home.

This virus was especially deadly to nursing home residents. The reasons for this are worthy of book-length treatment. The takeaway for me is that many people will be avoiding nursing homes like, well, the plague that they have been for many occupants.

The disease spurred telemedicine and digitized health technologies. You now can put a device on your wrist that generates real-time health readings and a 24-7 connection with a health care professional. At-home health technology companies say a shortage of Internet broadband service often has been the only serious obstacle to quicker implementation of home-based care programs. Cue the infrastructure bill!

I can’t tell you the fate of proposed increases in health spending being debated in Washington. But it seems likely that Medicare will be expanded and that coverage for at-home health care will be included in the package of enhanced benefits. Providing more funds will accelerate trends already in place that favor more at-home care.

Last year, when many hospitals were overwhelmed with COVID patients, some hospitals began expanding home-based care to free up beds. This real-world experiment has produced some appealing interim findings that home-based care can be as effective as hospital care and is much cheaper.

Brigham and Women’s Hospital in Boston is a leader here. Avera Health, based in South Dakota, at one point was treating nearly 1,150 patients in their homes. Boosted in part by expanded Medicare support for home-based care during the pandemic, nearly 100 hospitals across the country are in the program providing acute care to patients who would formerly have been hospitalized.

If these trends do come together, as I suspect, the impact on the senior care industry and real estate markets could be enormous. People will no longer regard nursing homes as their only source of long-term care.

The appeal of high-end continuing care retirement communities may also dim. Why spend $500,000 for a 1,200 square-foot apartment, and then $5,000 a month for a meal plan and related services? Why not have the care you need delivered for much less money to you in your own (much larger and nicer) home?

It will take many years for these changes to become commonplace. But anyone beginning to plan for their later years should include the development of at-home health care in their thinking.

 

 

 

Research about strategies for successful aging

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In a world that often seems short on facts and distressingly long on opinions, there’s nothing to beat a solid report from the Society of Actuaries, a group dedicated to fact worshippers!

A recent report from the SOA Research Institute provides a solid foundation for many of the common-sense lifestyle behaviors that most of us know we should pursue to live longer and healthier lives. The title is hardly clickbait — Maximizing Health Span: A Literature Review on the Impact of a Healthy Lifestyle on Retirement. And nearly half of the document is devoted to 346 research references.

The report’s review yields a distilled ranking of the things most likely to either kill older people or, equally important, rob their later years of enjoyment due to disabilities and steep health costs. The expression of these behavioral liabilities is labelled “health span,” which is defined as the difference between your remaining life span and the number of those years you spend in good health.

The culprits here won’t surprise you. “For both the pre- and post-retirement age groups,” the report says, “the five risk factors with the largest impacts on long and healthy lives are tobacco use, high body-mass index, high fasting plasma glucose, dietary risks, and high blood pressure.”

Getting a health span grade of zero would be a good thing, of course. A more clinical expression of this goal, which I obsessed over in my Medicare book, is “compressed morbidity” – to me, at least, a morbidly appealing concept.

Getting to zero is, however, a difficult journey and requires navigating a world of multiple medical challenges and complex inter-relationships that create their own risks. Not to worry, the SOA researchers note, “the Global Burden of Disease (GBD) Studies from the Institute for Health Metrics and Evaluation (University of Washington) is a comprehensive model that organizes these complicated relationships.”

When the dust clears from all this fact-based number crunching, the report notes that “while life expectancy at age 65 in the United States has climbed to 19.6 years, healthy life expectancy lags at only 13.1 years, and adults at age 65 can expect to live only 6.47 additional years in good health, on average.”

Here are verbatim snippets from the report about the leading health challenges we face and the quality-of-life benefits from confronting them:

Tobacco Use

Smoking trends in the U.S. are encouraging – amongst U.S. individuals aged 65-69, daily smoking prevalence decreased from 13.7 percent in 2000 to 11.1 percent in 2015, mirroring the overall decline in smoking prevalence amongst the U.S. population. (Interestingly, dietary and smoking risks tend to improve with age, whilst the converse is seen with the other factors that shall be explored. Smoking cessation prior to age 40 leads to the greatest gains in life expectancy (individuals who quit smoking between ages 25 to 34 gain an average of 10 years relative to those who continue smoking); however, even as one approaches retirement age, individuals who stop smoking between ages 45 to 54 stand to gain 6 extra years of life relative to those who continue smoking.

Body Mass Index (BMI)

As of 2017-2018, approximately 42.4 percent of United States adults were obese, a figure that has seen startling increases from 30.5 percent since 1999-2000. The prevalence of obesity persists amongst older adults – amongst those aged 65 to 69, 33.9 percent were obese. This number has increased since 2000, when – according to GBD data, amongst U.S. adults aged 65 to 69 – 25.3 percent were obese. According to 2019 GBD data, almost 12 percent of deaths (a 22.9 percent increase since 1990) and 11.3 percent of years lived in disability (a 47.5 percent increase since 1990) amongst adults 70 years and older were attributable to high BMI.

Metabolic Risks (Fasting Plasma Glucose, Blood Pressure, Cholesterol)

Amongst U.S. adults 70 years and older, 39.5 percent of deaths (a 15.6 percent decrease since 1990) and 25.9 percent (a 15.9 percent increase since 1990) of years lived in disability were attributable to metabolic risks. (Geek alert!) This excess risk is measured against minimum exposure thresholds of 4.8-5.4 mmol/L for glucose, 110-115 mmHg for systolic blood pressure, and 0.7-1.3 mmol/L for LDL cholesterol.

Dietary Risks

Amongst U.S. adults 70 years and older, 14.8 percent of deaths (a 28.9 percent decrease since 1990) and 5.2 percent (an 18.4 percent increase since 1990) of years lived in disability were attributable to dietary risks.

With age, several associated nutritional changes may affect quality of life, which makes the provision of a healthy diet even more important. These include reduced thirst and decreased body water, which increase susceptibility to dehydration; age-related changes in nutrient needs, which can lead to vitamin deficiency or toxicity; changes in taste, vision and smell, which can lead to decreased enjoyment of food; broken bones; edentulous, or missing or false teeth, which can limit food choices; increased disease incidence, which can lead to changes in nutritional requirements; increased use of over-the-counter or prescription drugs, which can lead to changes in appetite, nutrient requirements and increases in possible drug-nutrient interactions.

Physical Activity

In older adults, physical activity is associated with improved performance of daily activities, prevention of falls, improved quality of life in those with arthritis, increased longevity, lower risk of cognitive decline, and an increased sense of purpose in life. Even light/mild activity has been shown to have positive effects on healthy aging in older adults.

Older adults should at least try to incorporate multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Most evidence supports a program of exercise with the following characteristics: three times per week of balance training and moderate-intensity muscle-strengthening activities for 30 minutes per session, with additional encouragement to participate in moderate-intensity walking activities two or more times per week for 30 minutes per session.

The report also includes other behaviors that can greatly effect longevity and successful aging. These include paying attention to health screenings and immunizations, social engagement activities, adequate sleep, vision and hearing care (to which I’d add dental care), continuing to look for and engage in purposeful pursuits, managing the six ADLs, or activities of daily living (mobility, eating, dressing, bathing, toileting, and continence), and successfully aging in place in a home with “age friendly” modifications to minimize falls and other senior unfriendly challenges.

There will NOT be a later quiz on these extensive data points. Or excessive rants to “do the right” things. The facts are, well, the facts. How you respond to them is your call.

In the meantime, please raise your glasses in a toast to compressed morbidity!